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Khan. Im here with professor laurence baker. At stanford medical school and what we were going to talk about now is the overview of the health care system baker.
What is the health care system salman khan. Yeah. And whos in it.
Laurence baker. And whos in it. And what are they doing salman khan.
I think i could give a go at it. Laurence baker go for it salman khan. And then correct me expose my ignorance so clearly you have your providers.
Those would be your doctors and nurses and all the rest. Laurence baker. Hospitals pharmacies all kinds of people are your providers.
Salman khan. Ok. So everyone whos providing health care.
So thats right over there. So thats hospitals doctors pharmacies. All the rest and then they are providing the health care to someone so those would be the patients.
Let me do that in another color. Laurence baker call them patients. Yeah.
Sometimes you get the details like people become patients after they need health care. But some people just have a question theyre not really patients theyre just. Asking.
Salman khan. Ok. What would you call them.
Then. Laurence baker. Call.
Them. Population. Salman khan.
Population. So just the population of the world. Or of the country or whatever.
People and then someone has to pay for this and so for the most part this is insurers laurence baker yup insurance companies in the olden days like if you go back 100 years. We didnt really have insurers. We had patients and providers and patients would if they had a question they had a concern they go to the provider.
Theyd make some deal pay them some money do some service for them and work it out we got insurance companies really only in the last 100 years maybe really starting in the us in maybe 1930 1940. They started to become popular. So thats kind of a new renovation and those three things work together salman khan.
And the general term and this is a word. Ive seen a lot and sometimes its a little confusing. Because its very close to payer you hear of these payors and that would be including anyone whos paying for the paying for the service and insurance companies would be included there.
Laurence baker. Right so we have we call them payors sometimes we call them health plans. Because they arrange for some of the care that people get and payors could be private insurance companies or they could be government payors government insurance companies like medicare.
Salman khan and the insurance companies themselves. Theyre not doing this out of the goodness of their heart. Someone is paying them and for the most part in the united states it tends to be employers.
Laurence baker. So right so if we made another arrow on your diagram here it would be from the population or maybe from the patients to the insurance companies that provides the money for the insurance companies to use to pay for the provider. So patients might buy an insurance company or not an insurance company buy an insurance policy salman khan.
Only if theyre very well healed laurence baker. Some of them buy the whole thing. But they just might buy their own policy.
Go buy. An insurance policy pay them a premium directly the insurance company collects that money or for most people they work for an employer. The employer makes the arrangement to buy that insurance and then implicitly charges the population.
The patients for that maybe directly by having them contribute some of their salary maybe implicitly by just reducing the amount of cash they give them every month and instead giving them this insurance policy. So people do that and the other piece thats floating around in here is that in some cases. The population pays taxes to the government that then functions essentially as an insurer like the medicare program.
Where theres insurance. Provided to people thats paid for by taxes. So theres some different funds flows going around here.
But always money going from patients to insurers through employers from taxes by direct payments those insurers collecting the money and then paying for a bunch of the care. Thats provided by the providers. And thats the basic arrangement.
Theres one more tiny piece. Which is that sometimes patients pay the doctors or the hospitals directly you go you have a 20 co payment. And so theres a small payment that goes back and forth salman khan.
Your copay is kind of there just so that it kind of makes the insurance company feel good that youre not just using. It willy nilly that you have to pay your 10 or 50. Laurence baker.
Absolutely so insurers know that once they start paying the providers for the care and the patient says. Its totally free people might use stuff that might be worth a little tiny bit. But it costs a lot for everybody to pay for so.
If you put a co payment on there it makes people think twice about using things that they dont really need salman khan. Right that makes complete sense and then within this ecosystem. We hear a lot about hmos.
My perception is thats a combination of the insurance company and the provider. Its kind of in one package. Laurence baker.
Right so over time. The us has had different kinds of insurers out there in the private market especially. Theres been a lot of innovation in the last 30 40 years in types of insurers.
That are out there so we have different insurers that have behaved in different ways as weve gone through those evolutionary cycles. So one version of that is what we call an hmo. A health maintenance organization and thats really just jargon you have to dig into it to figure out what it means.
But in a lot of cases. What that is is a company thats acting as insurance. So you pay a premium to them if youre a patient or a person and you buy some coverage and then theyll cover your care.
But theyll do that by trying to integrate themselves with the providers. And so the organizations either are integrated. Because the hmo hires doctors directly or maybe owns.
The hospitals like kaiser permanente. For example or in some cases. Its a contractual relationship.
Its not exactly the same salman khan. So not all of them is tightly linked as a kaiser. Where its like you go to this building that says kaiser on it and thats where your doctor is it could be doctors just have their practices.
But theyre tightly linked with a i think thats how what blue shield or one of those laurence baker yeah blue shield or aetna or some of these different companies and you can start to dig into the details and every one will be a little bit different from the other but theyre contractual relationships. Salman khan. And the difference.
I think this is something everyone faces when they sign up with insurance with their employer. I had to do it recently is they all say you have to pick hmo versus ppo and theyre. Within the same policy and so my perception.
Is hmo is you have set list of doctors that they probably pre negotiated pricing with laurence baker. Yeah. So the difference between hmos and ppos gets a little bit into the details.
Salman khan. Ok. I dont want to get too.
Into. Laurence baker. We can sort of think about it in the way that youre talking about it.
So an hmo will have a list of doctors that youre supposed to see. And youll have to go see the doctors on that list and a stereotypical one if you dont see the doctors on that list. The insurance companys not going to pay for you care youre going to pay for yourself.
And in the stereotypical hmo. Theres going to be a fairly tight management between the insurance company and the doctors about whats going to be done. Whats allowable and so on salman khan.
And in the most tightly linked case. Theyll be the same. They doctors will be employed by the company.
Thats like kaiser. Laurence baker. As you think about it as a spectrum.
If you move a little bit away from that to a ppo. Whats happening in a ppo is youre still going to get a list. So youre going to be encouraged to see those doctors.
But maybe itll be a little more flexibility like if you decided not to see someone on the list. The plan would still pay some amount maybe not as much as they would if you saw someone on a list. But something whereas in an hmo maybe nothing and the plan will probably work a little less hard at managing.
What those doctors are doing to try and limit access to say high cost services. Hmo will tend to work harder ppo tends to work a little less hard. So its a little bit of a spectrum.
Youre kind of moving from more managed and more concentrated to a little less managed. But still more so than the system. We had say in the50s or60s.
Where anybody went to any doctor and any doctor. Did whatever they wanted and the insurance company just paid. The bill and there was no integration.
So its a little bit of a salman khan. So thats the main motivation. Why insurance companies are trying to get more integrated with the providers is because just like you said in the50s and60s.
You have the provider providing a service and obviously the patient like the service and then you have a third party paying for it and so theres no check on the person deciding and the person getting it says yeah. Lets get more service and someone else is right. Laurence baker.
So we created a big issue. Insurance companies are kind of an interesting thing in a health policy. World because we have to have them we have to have them to manage the risk associated with getting sick you get sick.
Today and get a huge bill and so we cant leave people on their own for that we got to have insurance companies. But as soon as you create insurance companies and i can have implicitly all my neighbors pay for the health care that i want then i might start using things that turn out to be an efficient and so you got to have them insurance companies. But you got to manage what happens.
When you have them also and so thats the integration between providers or co payments and utilization review. And all these things are basically attempts by insurance companies to try and manage. What economists would call the moral hazard.
The using additional services that you dont necessarily need because everybody else is going to pay for it for you salman khan. It makes complete sense well thanks that makes a ton of sense. .
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